Evidence for motivational interviewing in educational settings among medical schools: a scoping review

Background Motivational interviewing (MI) is a person-centred approach focused on empowering and motivating individuals for behavioural change. Medical students can utilize MI in patient education to engage with patients’ chronic health ailments and maladaptive behaviours. A current scoping review was conducted to 1) determine the types of MI (conventional, adapted, brief and group MI) education programs in medical schools, delivery modalities and teaching methods used; 2) classify educational outcomes on the basis of Kirkpatrick’s hierarchy; and 3) determine the key elements of MI education via the FRAMES (feedback, responsibility, advice, menu of options, empathy, self-efficacy) model. Methods This scoping review was conducted via the framework outlined by Arksey and O’Malley. Two online databases, CINAHL and MEDLINE Complete, were searched to identify MI interventions in medical education. Further articles were selected from bibliography lists and the Google Scholar search engine. Results From an initial yield of 2019 articles, 19 articles were included. First, there appears to be a bimodal distribution of most articles published between the two time periods of 2004--2008 and 2019--2023. Second, all the studies included in this review did not use conventional MI but instead utilized a variety of MI adaptation techniques. Third, most studies used face-to-face training in MI, whereas only one study used online delivery. Fourth, most studies have used a variety of interactive experiences to teach MI. Next, all studies reported outcomes at Kirkpatrick’s Level 2, but only 4 studies reported outcomes at Kirkpatrick’s Level 3. According to the FRAMES model, all studies (n=19; 100%) reported the elements of responsibility and advice. The element that was reported the least was self-efficacy (n = 12; 63.1%). Conclusion Our findings suggest that motivational interviewing can be taught effectively in medical schools via adaptations to MI and a variety of teaching approaches. However, there is a need for further research investigating standardized MI training across medical schools, the adequate dose for training in MI and the implementation of reflective practices. Future studies may benefit from exploring and better understanding the relationship between MI and self-efficacy in their MI interventions.


Background
Motivational interviewing (MI) is a person-centred approach that focuses on empowering and motivating individuals for behavioural change [1].Undoubtedly, the empathetic approach of MI in clinical settings fosters a supportive environment that encourages discussion of the benefits of enhanced self-care [2].In this context, MI practitioners utilize a set of essential skills encapsulated by the acronym "OARS", which stands for O = openended questions, A = affirmations, R = reflections and S = summaries to promote active listening [3].MI was developed primarily for the treatment of addiction disorders but has since progressed to include other physical and mental ailments as well [4].In a study on MI interventions in alcoholism, Miller & Sanchez [68] identified six common motivational elements that should be covered, represented by the acronym "FRAMES", where F = feedback (e.g., personalized feedback on the impacts of alcoholism on the client's own experiences, as opposed to providing generic information); R = responsibility (e.g., empowering clients to make their own choices and take responsibility for their change process); A = advice (e.g., effectively given in a nondirective and noncoercive manner); M = menu (e.g., offering a variety of choices on transition methods and plans); E = empathy (e.g., rendering empathic, reassuring and reflective listening); and S = self-efficacy (e.g., supporting clients to succeed in a specified goal).This review used the FRAMES model to determine the key elements of MI education.FRAMES was a predecessor to MI and was initially designed to address drinking problems [5]; however, it is also used in other health issues, such as decreasing stroke risk [6], substance use screening and brief intervention [7].The FRAMES model offers a structure that can be used to improve the delivery of MI by ensuring that key elements of MI are present in educational interventions.

Mechanisms of motivational interviewing
Frey et al. [8] developed mechanisms of the motivational interviewing (MMI) framework and described the mechanisms of fidelity of practice in MI, including a technical component, a relational component and MI-inconsistent practices [8].The technical component consists of the interviewer's ability to evaluate the participant's language relating to a specific behaviour change target and then build a conversation that evokes change talk.The relational component includes respect for the participant's self-determination, appropriate empathy, and equal partnership.Non-MI consistent behaviours include confrontation, offering unsolicited advice, and persuasion.Additionally, it is important to identify and understand the mechanisms of change so that MI users and researchers can focus on these mechanisms during training, which can lead to improved outcomes and fidelity [8].

Types of motivational interviewing
MI can be categorized into four types: conventional, adaptive, brief, and group.Conventional MI is an evidence-based approach and directive form of interviewing developed by Miller & Rollnick [9].Throughout the course of MI, four important tasks occur: engaging (building mutual relationships), focusing (setting goals), evoking (developing clients' motivations for change) and planning (negotiating change) [9].In this review, the term conventional MI is defined as an approach that utilizes MI-consistent tasks and behaviours in multiple sessions that target an identified population of clients.
Adapted MI consists of culturally sensitive MI and digitally supported interventions that can be used as adjunct interventions to the primary behavioural program [10].This review defines the term adapted MI to include any adaptations made to adapt MI culturally to the setting or delivered by technology through various types of technologies and content (e.g., computers, smartphones, applications, videos and audio).Additionally, it also includes adaptations made to structured curricula, such as using role plays or real patient interactions to facilitate the learning of MI.
Brief MI is a type of MI with varying lengths, ranging from 5--90 minutes in duration, emphasizing the lack of an accepted definition of brief MI [10].This review defines the term brief MI as an MI that provides brief consultations centred on typically fewer sessions (e.g., 1--2 sessions) than conventional MI (e.g., 3--4 sessions or more).
Group MI can be defined as groups of clients that apply the MI spirit, processes and methods to increase motivation for change and promote beneficial collaboration among participants and practitioners in a shared location to encourage change [11].This review defines the term group MI as MI that is adapted for group format and is MI consistent (e.g., applying MI principles, spirit and techniques in its delivery).
Additionally, MI can be used in patient education to help patients better handle their chronic health conditions and maladaptive behaviours.Therefore, behavioural change is vital in the recovery course of different mental and physical disorders, as a change to a healthier lifestyle has been shown to result in a significant decrease in chronic disease risk [12].More than 120 studies have demonstrated the efficacy of MI in addressing a wide range of problematic behaviours, such as substance abuse and risky behaviour, as well as promoting healthy behaviours [13].There is specific evidence regarding the effectiveness of MI across different health behaviours (substance abuse, risky behaviours and promoting health behaviours), according to the types of MI: conventional, adaptive, brief and group.For conventional MI, research has shown effectiveness in treating substance abuse [14], reducing risky behaviours in human immunodeficiency virus (HIV)-positive men [15] and promoting physical activity in older adults [16].Adaptive MI has demonstrated its effectiveness in reducing alcohol problems in women [17], reducing risky sexual behaviours and psychological symptoms in HIV-positive older adults [18] and promoting self-management to reduce BMI and improve lifestyle adherence with a computer assistant [19].Brief MI has been effective in reduction in alcohol misuse in college students with attention deficit hyperactivity disorder (ADHD) [20] and improvement in the engagement of physical activity in patients with low physical activity levels [21].Research has revealed that group MI is effective in treating drug use among women [22], reducing risky sexual behaviour among adolescents [23] and improving self-efficacy and oral health behaviours among pregnant women [24].
Unhealthy lifestyle-linked behaviours characterize common preventable risk factors that lead to the majority of noncommunicable diseases and their associated mortality and morbidity [25].MI provides an approach for healthcare providers to assist patients in investigating and resolving their ambivalence toward changing unhealthy lifestyle behaviour [27].Studies have reported the effectiveness of teaching MI to medical students [4,26,[28][29][30].Therefore, considering the prevalence and widespread application of MI in health care settings, this underscores the importance of MI being taught in the initial stages of medical education.
In a recent systematic review, Kaltman and Tankersley [31] reviewed MI curricula in undergraduate medical education (UME) and revealed important findings.Their research findings suggest that generally being involved in an MI curriculum can be linked to enhanced MI-related knowledge and skills in the short term.Additionally, they noted that 1) the MI curricula were heterogeneous in nature; 2) the curricula were different in terms of timing, duration and number of sessions; 3) the curricula employed in studies were multiple pedagogies; and 4) the quality of the evaluations and research evidence varied.However, this review by Kaltman and Tankersley [31] was limited to reporting only on MI-specific outcomes such as knowledge, skills, attitudes towards, and self-efficacy in implementing MI.Kaltman and Tankersley [31] systematic review did not stratify and explore in detail studies on the types of MI (conventional, adaptive, brief, or group).Furthermore, the systematic review did not investigate the key elements of MI education as described by the FRAMES model.The scoping review aimed to bridge the knowledge gap on types of MI (conventional, adapted, brief, group MI) and key elements of MI education covered via the FRAMES model.Specifically, the objectives of this study were to 1) determine the types of MI education programs in medical schools, the delivery modalities, and the teaching methods used; 2) classify educational outcomes on the basis of Kirkpatrick's hierarchy [32]; and 3) determine the key elements of MI education covered via the FRAMES model.

Procedure
This study adopted the methodological 5-step framework of Arksey and O'Malley for this scoping review.The five steps are as follows: 1) define our research objectives; 2) identify relevant studies; 3) identify studies based on our selection criteria; 4) chart and analyse the data; and 5) collate, summarize, and disseminate the results.

Eligibility criteria
Relevant peer-reviewed articles on MI studies conducted in medical education settings, published in academic journals only, in the English language, with no time limit imposed on the publication period, were identified.Studies involving nonmedical students as well as grey literature, such as conference proceedings, technical reports, videos, and informal communications, were excluded.Studies in languages other than English were also excluded.The search strategy was guided by the methodology of Aromataris and Riitano [33].The Boolean operators and keywords used in this search strategy were ("medical education" OR "medical teaching*" OR "medical graduate*" OR "medical postgraduate*" OR "medical student*") AND ("motivational interview*" OR "motivational enhanc*" OR "motivational chang*" OR "motivational behavior") AND ("psycholog*" OR "health*").The search utilized databases from the Medical Literature Analysis and Retrieval System Online (MEDLINE Complete) and Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete) databases via the EBSCOHost database search query, covering all study designs (i.e., quantitative, qualitative, and mixed studies).The protocol was developed a priori before the search process was conducted, including establishing the objectives and eligibility criteria for determining the studies selected.The reference lists of the selected studies were further checked for additional sources, including traditional and systematic reviews.Articles that met the eligibility criteria were selected through a consensus among the authors and were charted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) guidelines [34].
The first author conducted the searches and screened the articles using the search strategy and the inclusion and exclusion criteria stated above.This process resulted in the identification of 59 articles.The decision process resulted in 19 studies for inclusion in this review based on the inclusion and exclusion criteria.The data were extracted and charted by the first author.Notably, the following data were extracted: 1) the study characteristics of the identified articles (publication year, country of origin, type of MI, and medical student phase) and 2) a detailed description of the key findings of the articles (i.e., author, year, objectives, participants, delivery, duration, teaching methods, assessments, and educational outcomes based on Kirkpatrick's hierarchy).Proforma was developed by all the authors and used to extract and chart the data.The study characteristics are then charted in Table 1, and detailed descriptions of the key findings of the articles are charted in Table 2.The other authors assisted in identifying specific data elements to be charted onto Tables 1 and 2. All the authors contributed to analysing the charted data to ensure the consistency and accuracy of the analysis.The outcomes of educational intervention were classified under the four levels of Kirkpatrick's hierarchy.Studies classified as Level 3 consists of simulations and observations of behaviours in activities (e.g., roleplay, standardized patients, real patients) after a learning activity such as a workshop.Although Level

Results
From an initial pool of 2,019 articles, after removing duplicates and screening for relevance, 19 articles were included in this review.The detailed selection process is illustrated in the PRISMA flow diagram in Fig. 1.

Characteristics of the identified articles
The study characteristics, country of origin, and phase of study are presented in Table 1.The detailed descriptions of the key findings of these articles (i.e., author, year, objectives, participants, delivery, duration, teaching methods, assessments, and educational outcomes based on Kirkpatrick's hierarchy) are provided in Table 2. Most of the studies were published between 2004-2008 and 2019-2023, with each period accounting for 31.5% of the total articles.The majority of MI studies originated from the US (57.8%).
Adapted motivational interviewing was utilized in 8 studies.This approach includes any adaptations utilized to adjust MI culturally to the situation or facilitated by technology via different types of content and technologies (e.g., computers, smartphones, applications, videos and audio).Additionally, it also includes adaptations made to structured curricula, such as using role plays via standardized patients or real patient interactions to facilitate the learning of MI.Adapted MI was reported in 8 studies.Specifically, 5 studies [36,38,42,44,47] adapted their curricula to teach MI via role playing standardized patients or real patients.Additionally, 3 studies [4,46,49] utilized technological adaptations and blended learning (face-toface and online) to teach motivational interviewing.
In group MI, this approach consists of MI that is adapted for group format and is MI consistent (e.g., applying MI principles, spirit and techniques in its delivery).Group MI was carried out in 7 studies.Two studies [26,45] used training workshops to teach and practice MI in smaller groups.The remaining 5 studies [29,35,39,40,48] used a small group format to teach MI skills consisting of lectures, roleplay, a case-based curriculum and demonstrations.Brief MI provides brief consultations centred on typically shorter number sessions (e.g., 1--2 sessions) than conventional MI (e.g., 3--4 sessions or more).A brief MI was conducted in 4 studies.Two studies [41,51] delivered a single session of MI training within two hours.Another study [50] conducted four (10-15 minute) sessions teaching MI, with a total of less than 1 hour of training.Opheim et al. [43] conducted a four-hour workshop on MI, which is a relatively brief training intervention.

Classifying educational outcomes based on Kirkpatrick's hierarchy
With respect to the second research objective (i.e., classifying educational outcomes on the basis of Kirkpatrick's hierarchy [32]), all 19 studies [4,26,29,35,36,[38][39][40][41][42][43][44][45][46][47][48][49][50][51] were categorized at Kirkpatrick's Level 2 (knowledge/ skills/attitudes).This is followed by 16 out of 19 studies [4,26,29,35,36,39,40,[43][44][45][46][47][48][49][50][51] categorized at Kirkpatrick's Level 1.Only 4 out of 19 studies [35,38,41,47] are categorized at Kirkpatrick's Level 3 (Behaviour).One of the studies [38] compared the effectiveness of standardized patients versus role plays from colleagues and reported that both were equally effective for teaching basic MI skills among medical students.The students were evaluated in a simulated environment and demonstrated their MI skills in terms of student roleplay or standardized patients.The study reported that standardized patient role play is as effective as student role play in teaching basic MI skills.The sessions focused on demonstrating skills in a simulated setting, suggesting that the student's behaviour (i.e., adherence to MI skills) was evaluated and improved via the educational intervention.In another study, Bell et al. [35] investigated the use of a curriculum to teach medical students the principles of MI to increase their knowledge, skills and confidence in counselling patients with the aim of health behaviour change.The research indicated that video-recorded interactions between students and patients enabled students to effectively apply MI skills to real-life patients.None of the studies included reported outcomes at Level 4 (results).
The primary assessment method used across the studies was the use of pre-and posttest surveys, which are used to measure knowledge (n=10, 52.6%), skills (n=5, 26.3%) and attitudes (n=3, 15.8%) pertaining to MI.Moreover, the specific instruments employed for focused assessments were

Discussion
Our scoping review sheds light on the current trends and key findings to determine the types of MI education programs in medical schools, the delivery modalities and teaching methods used, classify educational outcomes on based on Kirkpatrick's hierarchy [32] and determine the key elements of MI education covered via the FRAMES model.First, there appears to be a bimodal distribution of most articles published between the two time periods of 2004--2008 and 2019--2023.Second, all the studies included in this review did not use conventional MI but instead utilized a variety of MI adaptation techniques.Third, most studies used face-to-face training in MI, whereas only one study used online delivery.Fourth, most studies have used a variety of interactive experiences to teach MI.Next, all studies reported outcomes at Kirkpatrick's Level 2, but only 4 studies reported outcomes at Kirkpatrick's Level 3. Finally, the most covered elements of MI training in these studies were responsibility and advice (n = 19; 100%), and the least covered element in MI training was self-efficacy (n = 12; 63.1%) [4, 29, 35, 36, 39-41, 44-46, 48, 51].This review expands on the evidence of MI interventions among medical schools.The results of our findings generally suggest that MI can be effectively taught in medical schools.Furthermore, we have provided several recommendations for further research to improve the implementation of MI in medical schools.
There appears to be a bimodal distribution of published articles between the two time periods, i.e., between 2004 and 2008 and between 2019 and 2023.A decline in the number of articles published was observed between 2009 and 2019.This decline could be due to the shift in the applications of MI beyond treating addictive behaviours to include a broad range of other behavioural conditions [52], such as its expanded applications in school education [53][54][55], lifestyle coaching [56][57][58], probation and parole [59,60] and digital health care and telemedicine [61,62].From 2019 onwards, however, there was an increasing trend in the number of published articles on MI training for medical students.This could be attributed to the MI Network of Trainers (MINT) making it mandatory to attend MI training during the COVID-19 pandemic to provide virtual training in 2020 and 2021 [52], which has facilitated remote participation.

Types of MI education programs in medical schools
All the studies included in this review did not use conventional MI but utilized a variety of MI adaptation techniques.Most studies [4,36,38,42,44,46,47,49] have used adapted MI to conduct their MI training, possibly because of the need to tailor MI programs to fit medical school curricula.Medical students have been linked to extensive academic responsibilities and clinical rotations [63], contributing to this adaptation of MI.In fact, the lack of harmonization of training methods among medical schools has led to challenges in understanding the optimal approach to teach MI among medical students [31].Furthermore, there is no consensus on the standard dose of training in MI that is adequate or mandatory for learners to acquire sufficient skilfulness in the practice of MI [9].Moreover, medical schools have time constraints and limited MI teaching opportunities because of their hectic medical curriculum schedules [41].This may lead to a variety of adaptations of MI, as noted in this review.Future research can focus on addressing the lack of harmonization in MI training methods and emphasize building and employing standardized MI training with adequate dosing across medical schools.

Delivery modalities and teaching methods used
In the present review, the delivery modalities used to train medical students in MI varied across the studies.Most studies [26, 29, 35, 36, 38-45, 47, 48, 51] have focused on delivering face-to-face training on MI to clinical medical students.This aligns with the current literature, which suggests that MI is a complex communication skill [57] and is reported to be taught more effectively in face-to-face sessions [64].In this review, only one study [50] used a fully online approach to teach MI to medical students.A systemic study suggested that for an online MI intervention to be effective, it requires significant emphasis on fidelity and training procedures [65].In a recent comparative study, Schaper et al. [66] reported similar effects of training MI among general practitioners in both online and face-to-face training in MI skills and spirit.Future studies could focus on the implementation of online versus face-to-face training for medical students with an emphasis on fidelity and training procedures for MI.
A large proportion of the studies in this review report the use of a variety of teaching approaches (e.g., workshops, role-play, standardized patients, and small and large group sessions) to teach MI.This aligns with Kolb's experiential learning cycle [67], where the process of learning occurs when knowledge is formed via the transformation of experience.This model is guided by four phases of the learning process: concrete experience (having an experience), reflective observation (reflecting on an experience), abstract conceptualization (learning from the experience), and active experimentation (experimenting what you have learned).Medical students who are given the opportunity to engage in Kolb's learning cycle [67] via interactive activities, reflection and simulated or real-life settings are likely to develop good MI skills.Future research should underpin educational theories into MI training by implementing structured reflective exercises in MI education.

Educational outcomes based on Kirkpatrick's hierarchy
Our review shows that all studies reported outcomes at Kirkpatrick's Level 2, suggesting that medical students have acquired the intended knowledge, skills, and attitudes.There are only 4 studies that reported outcomes at Kirkpatrick's Level 3, which evaluates the degree to which the students apply their learning to simulated or real-world settings.The first 3 studies [38,41,47] showed their improvement in behaviour by showing their learned skills in realistic settings, which included observing students' behaviour in standardized patients or real patients.The last study [35] revealed improvements in the MI skills of real patients in diverse settings, such as traditional health behaviour interventions, such as alcohol, tobacco and weight loss interventions.Future studies should include longitudinal evaluations of the effectiveness of MI skills.

Key elements of MI education covered via the FRAMES model
According to the FRAMES model [68], all included studies reported the elements of responsibility and advice (n=19; 100%) in the training of MI.The element responsibility is the shared responsibility of the learner's growth by the learner and teacher.This could be attributed to the move towards competency-based medical education, which emphasizes shared responsibility among students while incorporating student-centric learning techniques and formative assessment as a vital element of the learning process [69].In other words, the high reporting of 'responsibility' and 'advice' suggest that the present MI training significantly emphasizes medical students taking ownership of their learning and decision-making processes ('responsibility').Moreover, from a patient education perspective, empowering patients to take ownership of their health [70] and effectively guiding patients toward positive behavioural changes through good advice in a nonconfrontational approach is a basic tenet of MI ('advice').
The least reported element found in training for MI in our included studies [4, 29, 35, 36, 39-41, 44-46, 48, 51] was self-efficacy.This may be due to MI training focusing less on self-efficacy and instead emphasizing other elements, such as empathy, open-ended questioning and reflective listening.An educational theory that is linked to the element of self-efficacy is social cognitive theory.Social cognitive theory can be defined as a person's belief in their ability to determine the behaviours required to reach their desired goals and their perceptions of their ability and skills to manage their environment [71,72]

Limitations
This scoping review is subject to several limitations.We included only English-language studies in which medical students were the target participants.We did not include articles that are categorized as grey literature or other forms of nonpeer review articles, which might have resulted in biased outcomes.Most of the studies focused on evaluating learner knowledge and skills in MI, which might have limited the practical applications of MI to real patients.The first author conducted the search and screening of the articles.This may lead to selection bias and reduce the reliability of the study selection process.The protocol for this review was developed before the search was initiated but was not registered or published online, which increases the risk of selective reporting.The database search was limited to MEDLINE Complete and CINAHL Complete, which were accessed via EBSCOhost and the search engine Google Scholar.Although a comprehensive search was conducted, other databases that were relevant to the review, such as the PsycINFO and ERIC databases, were not included, potentially resulting in missing relevant articles.Kirkpatrick's hierarchy was utilized to assess educational outcomes in this review.This approach may neglect other core aspects of educational interventions.Furthermore, although we have extensively searched various countries, most of the studies reported are from the USA (n=11; 57.8%) or Germany (n=4; 21.0%).A lack of diversity among studies in other regions may lead to biased outcomes.

Conclusion
Based on our review, the findings suggest that motivational interviewing can be taught effectively in medical schools via adaptations of MI and a variety of teaching approaches.However, there is a need for further research investigating standardized MI training across medical schools, the adequate dose for training in MI and the implementation of reflective practices that are supported by educational learning theories.Furthermore, longitudinal studies can assess the effectiveness of MI.Future studies may benefit from exploring and better understanding the relationship between MI and self-efficacy in their MI interventions.The FRAMES model can be used to guide research and explore which aspects of FRAMES are optimally delivered within the limited time frame of medical curricula.

Fig. 2
Fig. 2 Important elements of MI interventions (n = 19) identified as "reported" via the FRAMES model . Continued research into integrating social cognitive theory into MI training could assist practitioners in comprehending the role and importance of self-efficacy in behaviour change and reflective practice.The lower reporting of 'self-efficacy' might also indicate a potential gap in MI training.Self-efficacy is essential because it relates to the practitioner's confidence in their ability to effectively implement MI techniques and facilitate behaviour change in patients.Addressing this gap in future research could lead to more competent and confident practitioners who are better equipped to address challenging patient interactions and support positive health outcomes.Future studies can also utilize FRAMES to guide research design and interventions and investigate which aspects of FRAMES in the training of MI are most effective within the limited time frame of medical curricula.

Table 2
Detailed description of the key findings of selected articles